On May 15, 2019, an amended version of Clinical Coverage Policy 10C, Outpatient Specialized Therapies, Local Education Agencies (LEAs), was posted to the North Carolina Medicaid website. The following updates were made in accordance with State Plan Amendment (SPA) NC 18-0005.
The following SPA-related updates became effective Oct. 1, 2018:
In Subsection 1.0 Description of the Procedure, Product, or Service, the following two bullets were updated to read:
- The service(s) are documented on the beneficiary’s Individualized Education Program (IEP), Individual Family Service Plan (IFSP), Individual Health Plan (IHP), Behavior Intervention Plan (BIP) or 504 Plan according to 34 C.F.R. 104.36; and
- Provided by school staff or contracted personnel.
In Subsection 2.1.2 Eligibility Requirements, Specific, Medicaid, criterion d. was deleted, and criterion c. was updated to read:
c. the beneficiary receives the service(s) in the public school setting or a setting identified in an IEP, or IFSP, IHP, BIP or 504 Plan, and is receiving services as part of an IEP, IFSP, IHP, BIP or 504 Plan.
In Subsection 3.2.2 Medicaid Additional Criteria Covered was updated to read:
- Medicaid shall cover audiology, counseling, nursing, occupational therapy, physical therapy, and speech/language therapy services that are medically necessary and documented on any one of the following: IEP; IFSP; IHP; BIP; or 504 Plan.
In Subsection 3.8 Psychological and Counseling Services, the list of areas of functioning was updated to read:
- Cognitive
- Emotional and personality;
- Adaptive behavior;
- Behavior; and/or
- Perceptual or visual motor
In Subsection 3.9 Evaluation Services, the following covered services were added:
3.9.1 Vision Screening Services
- Vision Screening Services must be administered by licensed registered nurses (RNs) or licensed practical nurses (LPNs) prior to providing a billable psychological evaluation, occupational therapy evaluation, physical therapy evaluation or speech/language evaluation service.
3.9.2 Hearing Screening Services
- Hearing Screening Services must be administered by licensed RNs, Audiologists or Speech/Language Pathologists prior to providing a billable psychological evaluation, occupational therapy evaluation, physical therapy evaluation or speech/language evaluation service.
In Subsection 3.11 Treatment Services, criterion b.6 was updated to read:
- For a Local Education Agency (LEA), the prior approval process is deemed met by the IEP, IFSP, IHP, BIP or 504 Plan processes. An LEA provider shall review, renew and revise the IEP, IFSP, IHP, BIP or 504 Plan annually along with and obtaining a dated physician order with signature. The IEP, IFSP, IHP, BIP or 504 Plan requirement of parent notification must occur at regular intervals throughout the year as stipulated by NC Department of Public Instruction. Such notification must detail how progress is sufficient to enable the child to achieve the IEP, IFSP, IHP, BIP or 504 Plan goals by the end of the school year;
Subsection 5.1, Prior Approval was updated to read:
- The prior approval process is deemed met by the IEP, IFSP, IHP, BIP or 504 Plan processes.
In Subsection 5.2, Limitations or Requirements, paragraph four, sentences one and two were updated to read:
- All treatment services shall be provided as outlined in an IEP, IFSP, IHP, BIP or 504 Plan. Occupational therapy and physical therapy services can be provided in a group setting with a maximum total number (that is both non-eligible and Medicaid-eligible beneficiaries) of three children per group.
Subsection 5.3, Location of Service was updated to read:
- The service must be performed at the location identified on the IEP, IFSP, IHP, BIP or 504 Plan.
In Subsection 7.2 Documenting Services, criteria c. and j. and paragraph two were updated to also include the IFSP, IHP, BIP or 504 Plan.
In Attachment A, Section C, Code(s), added V5008 (hearing screen) to Audiology, SLP and Nursing code lists; 99173 (vision screen) to Nursing code list; and 97150 (group therapy) to OT and PT lists.
Attachment A, Section C, Third Party Liability, was updated to also include the IFSP, IHP, BIP or 504 Plan.
In Attachment A, Section E, Treatment Services, the last sentence of paragraph one was deleted:
- All treatment services must be provided on an individualized basis except for speech-language services, which include group speech therapy with a maximum total number (i.e., both non-eligible and Medicaid-eligible beneficiaries) of four children per group.
Attachment A, Section F, Place of Service, was updated to also include the IFSP, IHP, BIP or 504 Plan.
These additional updates, unrelated to the SPA, became effective January 1, 2019:
In Attachment A, Section C, Code(s), the following updates were made:
- End-dated psychological and counseling evaluation CPT code 96101 was deleted and replaced with 96130, 96131, 96136 & 96137.
- End-dated psychological and counseling evaluation CPT code 96111 was deleted and replaced with 96112 & 96113.
- End-dated psychological and counseling evaluation CPT code 96118 was deleted and replaced with 96132 & 96133.
- Added 96121 which is new code paired with newly divided code 96116.
In Subsection 5.2, Limitations or Requirements, to the first sentence of paragraph three, the following language was added:
- Except where permitted by covered Psychological and Counseling Services Assessment procedure codes.
These additional updates, unrelated to the SPA, became effective May 15, 2019:
- In Subsection 2.1, Provisions, criterion b., the reference to NC Health Choice was deleted.
- Subsection 3.2.2, NC Health Choice Additional Criteria Covered was renumbered as Subsection 3.2.3.
- In Subsection 3.10, Treatment Plan (Plan of Care), added criterion i. treatment plan date, beneficiary’s name and date of birth or Medicaid identification number.
- In Subsection 6.1, Provider Qualifications and Occupational Licensing Entity Regulations, updated references to Federal Register qualifications for OT, PT, SLP and audiology.
Additional Resources
The full text of Clinical Coverage Policy 10C is available at North Carolina Medicaid’s Outpatient Specialized Therapy Services web page. Additional information can also be found at the ChoicePA website.